2017 ACLS Focused Update Takeaways - Management of Heart Failure

The information for the following review was obtained from the 2017 ACC/AHA/HFSA focused update on guidelines for the management of heart failure. The material was reviewed and published in the August 2017 edition of Circulation.

Biomarkers

Assays for BNP (B-type natriuretic peptide) and NTproBNP (N-terminal pro-B-type natriuretic peptide), which are both natriuretic peptide biomarkers, have been used increasingly to establish the presence and severity of HF. A substantial evidence base exists that supports the use of natriuretic peptide biomarkers to assist in the diagnosis or exclusion of HF as a cause of symptoms (eg, dyspnea, weight gain) in the setting of chronic ambulatory HF or in the setting of acute care with decompensated HF, especially when the cause of dyspnea is unclear.

Cardiac troponin levels may be elevated in the setting of chronic or acute decompensated HF, suggesting myocyte injury or necrosis. Troponins I and T respond similarly for acute coronary syndromes and acute decompensated HF. Elevations in either troponin I or T levels in the setting of acute HF are of prognostic significance and must be interpreted in the clinical context.

Biomarkers for Prevention: Recommendation

For patients at risk of developing HF, natriuretic peptide biomarker-based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF (Class IIa; Level B-R).

Biomarkers for Diagnosis: Recommendation

In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF (Class I; Level A).

Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF (Class I; Level A).

Measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF (Class I; Level A).

During a HF hospitalization, a pre-discharge natriuretic peptide level can be useful to establish a post-discharge prognosis (Class IIa; Level B-NR).

In patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification (Class IIb; Level B-NR).

Recommendations for ivabradine

Ivabradine is a new therapeutic agent that selectively inhibits the IF current in the sinoatrial node, providing heart rate reduction. The benefit of ivabradine was driven by a reduction in HF hospitalization. The target of ivabradine is heart rate slowing (the presumed benefit of action). Given the well-proven mortality benefits of beta-blocker therapy, it is important to initiate and up titrate these agents to target doses, as tolerated, before assessing the resting heart rate for consideration of ivabradine initiation.

Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) who are receiving guideline-directed management and therapy (GDMT), including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 bpm or greater at rest (Class IIa; Level B-R).

Recommendations for Stage C HFpEF

Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity (Class I; Level B).

Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF (Class I; Level C).

Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT (Class IIa; Level C).

Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF (Class IIa; Level C).

The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF (Class IIa; Level C).